Pregnancy is one of the wonderful gifts of God, imposed naturally to womanhood only. It is a period of enormous physio- pathological and psychological adoption in a women’s life. Pregnancy is a normal physiological process and not a disease, but it is associated with certain risks to health and survival both for women and infant she bears. Every minute of everyday a women dies of pregnancy related complications. Hypertension is one of the common problems met during pregnancy and contributes significantly to maternal and perinatal morbidity and mortality. Pregnancy-induced hypertension is one of the maternal diseases that causes the most detrimental effects to the maternal, fetal, and neonatal organisms. Pregnancy-induced hypertension is also called toxemia or preeclampsia. It occurs most often in young women with a first pregnancy. Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies.

1. PREPARED BY
MOUMITA MANNA

2. IT IS A MULTI SYSTEM DISORDER OF
UNKNOWN ETIOLOGY CHARACTERISED BY
DEVELOPMENT OF HYPERTENSION TO THE
EXTENT OF 140/90 mm Hg OR MORE WITH
PROTEINURIA AFTER 20TH WEEK IN A
PREVIOUSLY NORMOTENSIVE AND NON
PROTEINURIC WOMAN.

3. The presence of hypertension of at least
140/90 mm Hg recorded on two separate
occasions at least 4 hours apart and in the
presence of at least 300 mg protein in a
24 hours collection of urine arrising de novo
after the 20th week gestation in a previously
normotensive women and resolving
completetly by the sixth postpartum week.

4. DIAGNOSTICCRITERIA
 Hypertension- syst > 140mmHg
or 30mm above pre-preg
diastolic > 90 mmHg
or 15mm above pre-preg
Two abnormal measurements, on two occasions,
more than 4 hours apart

5. DIAGNOSTICCRITERIAcontd..
BOOK PICTURE
Mild symptoms
PATIENT PICTURE
Hypertension present (140/110)
Edema Present (face,arms,legs)
Proteinuria Present (2+)
Visual disturbance absent
Decreased urine output absent
Disturbed sleep absent

6. • Incidence
3% of pregnancies.
--Epidemiology
--More common in primigravida.
There is 3-4 fold increase in first
degree relatives of affected
women.

7. Etiology of preeclampsia
(Genetic predisposition)
(Abnormal immunological response)
(Deficient trophoplast invasion)
(Hypoperfused placenta)
(Circulating factors)
(Vascular endothelial cell activation)
(Clinical manifestations of the disease)

8. RISKFACTORS
 Young maternal age
 Nulliparity: 85% of pre-eclampsia occur in
primigravida.
 Increased placental tissue for gestational age:
Hydatiform moles, twin pregnancies
 Family history of pre -eclampsia
 Diabetes mellitus
 Renal diseases,
 Chromosomal abnormality in the fetus (eg,
trisomy).

9. RISK FACTORS cont
Worrisome signs for pre-eclapmsia development
 Rapid increase of weight during the latter ½ of
pregnancy
 An upward trend in diastolic BP even while still
within normal range

10. PATHOPHYSIOLOGY
 There are several theories and etiologic mechanisms.
 Vasospasm theory: Most favored theory
 Vasospasms → vasoconstriction → resistance → arterial BP
Eclampsia:
Cerebral arterial vasospasm → cerebral edema or infarction and/or
cerebral hemorrhage

11. Spasm of vessels
Vessel
stenosis
Higher periphery
resistance
Blood pressure
elevate
Injury of endotheliocyte
Proteinuria Edema Hypertension
Pathology

12. PATHOPHYSIOLOGY
OF
PRE-ECAMPSIA

13. PATHOPHISIOLOGY:-
Defective trophoplast invasion hypoperfused placenta
release factors (growth factors,
Cytokines) vascular endothelial cell
activation.
 Vasospasm hypertension
 Endothelial cell damage oedema,
hemoconcentration
 Kidneys,glomeruloendotheliosis proteinuria,reduced uric
excretion and oligouria.

14.  Liver,subendothelial fibrin deposition elevated
liver,hemorrhage,infarction,liver rupture and epigastric pain.
 Blood thrombocytopenia,DIC,HELLP syndrome.
 Placental vasospasm placental infarction, placental
abruptio& uteroplacental perfusion IUGR.
 CNS vasospasm&oedema headache,
visual symptons(blurred vision,spots, scotoma) hyperreflexia
and convulsions.

15. Symptomsof preeclampsia
1. Headache
2. May be symptomless
3. Visual symptoms
4. Epigastric and right abdominal pain
Signs of preeclampsia
1. Hypertension
2. Non dependent oedema
3. Brisk reflexes
4. Ankle clonus(more than 3 beats)
5. Fundal height

16. CLASSIFICATIONOF PREECLAMPSIA:
ACCORDING TO SEVERITY
1. Mild pre-eclampsia
2. Moderate pre-eclampsia
3. Severe pre-eclampsia
1. Mild to Moderate Pre eclampsia
Diagnostic Features
 Systolic BP is 140 -160 mmHg
 Diastolic BP is 90 – 110 mmHg
 Proteinuria up to ++

17. 2. Severe pre-eclampsia
Also called – Imminent eclampsia
Symptoms
 Severe & persistent occipital or frontal headaches
 Visual disturbance: blurred vision, photophobia
 Epigastric and/or right upper-quadrant pain
Signs
 Diastolic BP > 11ommHg, systolic BP > 160mmHg
 Proteinuria +++ or more
 Altered mental status
 Hyper-reflexia
 Oliguria

18. WHEN TO COME TO HOSPITAL

19. Investigations
Maternal
 Urinalysis by dipstick
 24 hours urine collection
 Full blood count(platelets & haematocrit)
 Renal function(uric acid,s.creatinine,urea)
 Liver function tests
 Coagulation profile

20. Fetal
1. Usg(growth parameters,fetal size,AFI)
2. CTG
3. BPP
4. Doppler

21. ManagementofpreeclampsiaPrinciples
 Early recognition of the syndrome
 Awarness of the serious nature of the condition
 Adherence to agreed guidelines(protocol)
 Well timed delivery
 Postnatal follow up and counselling for future pregnancy
 REMEMBER: Delivery is the only cure for preeclampsia

22. A. Mild preeclampsia
 Diastolic blood pressure 90-95mmhg
 minimal proteinurea,
 normal heamatological biochemical parameters,
 no fetal compromise. Deliver at term.
B. severe preeclampsia
 (BP>160/110MMHG,
 urine protein 5grams (3+ )
 Abnormal haematological and
 biochemical parameters,
 abnormal fetal findings
 Control blood pressure(aim to keep
BP 90-95mmgh )
M
A
N
A
G
E
M
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t
Principles

23. Management of labour
FIRST STAGE:
 Vital signs: BP measured half hourly, monitor respiratory rate,
LOC.
 Fluid balance: CVP inserted. IV fluids administered. I/O chart
maintained.
 Plasma volume expansion: colloid solution
 Pain relief: epidural analgesia given.
 Monitor fetal condition: FHR.

24. Delivery:-
 Transfer patient to tertiary center if her condition permits.
 If fetus is preterm give mother 12mg
 Dexamethasone im twice 12hs apart to enhance lung
maturity.
 Deliver c/s or vaginal.
 Avoid ergometrine in 3rd stage.
 Give anticoagulant.
Management of labour

25. SECOND STAGE:
 Obstetrician and pediatrician notified.
 Continue care of mother, and encourage her to deliver.
 Shorter 2nd stage of labor- forceps or ventouse.
THIRD STAGE:
 Ergometrine and syntometrine not to be used.
 Syntocinon is prefered.
CARE FOLLOWING DELIVERY:
 Monitor maternal condition every 4 hourly for 24 hours.
Management of labour

26. PREDICTION OF PRE-ECLAMPSIA
 Presence of diastolic notch at 24 wk gestation
 Absence of end diastolic frequencies
 Average mean arterial pressure
 Angiotensin infusion test
 Roll over test

27.  Early identification of women at risk for pregnancy-induced hypertension
may help prevent some complications of the disease.
 Education about the warning symptoms is also important because early
recognition may help women receive treatment and prevent worsening of
the disease.
 Regular antenatal check up
 Anti thrombotic agent
 Calcium supplements
 Antioxidants
 Nutritional supplements
 Adequate rest
PREVENTION OF PREGNANCY-INDUCED
HYPERTENSION:

28. COMPLICATIONS
 Eclampsia
 Oliguria /anuria
 Preterm labour
 Dimness of vision
 HELLP Syndrome
• Intra uterine death
• Intra uterine growth
restriction
• Prematurity
• asphyxia
MATERNAL FETAL
IMMEDIATE

29. REMOTE
Residual hypertension
Recurrent pre eclampsia
Chronic renal diseases
COMPLICATIONS

30.  HELLP syndrome is a complication of severe pre-eclampsia or eclampsia.
HELLP syndrome is a group of physical changes including the breakdown
of red blood cells, changes in the liver, and low platelets (cells found in the
blood that are needed to help the blood to clot in order to control bleeding).

31. Hemolysis, Elevated Liver Enzymes & Low Platelets- Weinstein (1982)
 Hemolysis = microangiopathic hemolytic anemia
 Platelets < 150,000
 Abdominal pain, nausea, vomiting, headache, edema
 AST (aspartame aminotransferase) > 70,
 LDH (lactic dehydrogenase)> 60
 May be complicated by renal failure, ARDS, electrolyte abnormalities and
hemorrhage

32. ECLAMPSIA
 Eclampsia is one or more convulsions in association with the
syndrome of pre-eclampsia.
 Eclampsia is a severe form of pregnancy-induced
hypertension. Women with eclampsia have seizures resulting
from the condition. Eclampsia occurs in about one in 1,600
pregnancies and develops near the end of pregnancy, in most
cases.

33. STAGES OF ECLAMPSIA
CLINICAL FEATURES: consist of 4 stages.
 Premonitory stage: patient is unconscious. There is
twitching of muscles of face tongue and limbs. Eye
balls roll or turned to one side and become fixed.
Last for 30 sec.
 Tonic stage: whole body goes into tonic spasm-trunk
opisthotonus (concave shape), limbs flexed ,hands
clenched, respiration ceases, tongue protrude
between teeth, cyanosis appear, eye balls become
fixed. last for 30 sec.

34.  Clonic stage: all voluntary muscles undergo alternate contraction and
relaxation. Twitching starts in face, involve one side of extremities and
whole body involved in convulsion. biting of tongue occurs. Breathing-
stertorous and bloody stained frothy secretions fill mouth. Cyanosis
disappears. Last for 1-4 min.
 Stage of coma: following fits patient passes on to stage of coma. Last for
brief period or till other convulsion.

35. MANAGEMENT
 First aid treatment outside hospital.
 Principles of management:
- maintain airway
-Oxygen
- arrest convulsion
- ventilator support
- deliver by 6-8 hrs.
- postpartum care.

36. General management
 Place in a railed cot in isolation room
 Detailed history
 Vital signs
 Fluid balance
 Antibiotics

37. Specific management
 Anticonvulsant and sedatives
 Magnesium sulphate
 Lytic cocktail regime
 Diazepam
 Phenytoin
 Antihypertensives and diuretics

38. MgSO4 THERAPY
REGIMEN LOADING DOSE MAINTAINENCE DOSE
I/M (PITCHARDS) 4 gm I.V over 3-5 mins followed
by 10 gm deep I/M (5 gm in each
buttock)
5 gm I/M 4 hourly in alternate
buttock
I/V (ZUSPAN OR SIBAI) 4- 6 gms I/V over 15 – 20 mins 1 -2 gms / hr I/V infusion

39. MgSO4
25% 2ML 500 GMS
1ML 250 GMS
50% 2ML 1GM
1ML 500 GMS

40.  Repeated injections are given only if
 - the knee jerk reflexes are present
 - urine output exceeds 30 ml/ hr
 - RR is more than 12 per minute
 - Therapuetic level of mgso4 is 4-7 Meq/l
 - antidote calcium gluconate

41. Lytic cocktail regime
 - 25 mg chlorpromazine, 100 mg pethidine in 20 ml of 5 % dextrose i/v
 - with 50 mg chlorpromazine,and 25 mg promethazine given I/M

42. GESTATIONAL HYPERTENSION
 Gestational hypertension refers to hypertension with
onset in the latter part of pregnancy (>20 weeks'
gestation) without any other features of pre-
eclampsia, and followed by normalization of the
blood pressure postpartum. Of women who initially
present with apparent gestational hypertension,
about one third develop the syndrome of pre-
eclampsia. As such, these patients should be
observed carefully for this progression.

43. Nursing Considerations
 Promote bed rest (either at home or in the hospital )
 Administer magnesium sulfate (or other antihypertensive medications
for PIH) as ordered to control hypertension & forestall seizures .
 steroid injections are administered to promote fetal lung maturation.
 Assist for continued laboratory testing of urine and blood (for changes
that may signal worsening of PIH)
 Assist in delivery of the baby (if treatments do not control PIH or if the
fetus or mother is in danger). Cesarean delivery may be recommended
in some cases.
 Pain management during labor.
 Appropriate fetal and maternal monitoring etc.

44. THA
NK